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Kinter S, Susarla S, Delaney JC, Chapman K, Kapadia H, Weiss N. Does Distraction Lower Risk of VPI Compared to Conventional Maxillary Advancement? A Retrospective Cohort Study of Adolescents with Cleft Palate. Cleft Palate Craniofac J 2024; 61:422-432. [PMID: 36373608 PMCID: PMC10752384 DOI: 10.1177/10556656221138895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE To determine whether method of maxillary advancement in adolescents with cleft palate with or without cleft lip (CP ± L) influences post-operative velopharyngeal function. DESIGN Retrospective cohort. SETTING Pediatric Tertiary Care Hospital. PARTICIPANTS One hundred and ninety-nine patients with CP ± L after LeFort I osteotomy for maxillary advancement at our institution between January 2007 and June 2019. INTERVENTIONS LeFort I osteotomy via distraction osteogenesis (DO) or conventional osteotomy (CO). MAIN OUTCOME MEASURES Patients who underwent DO or CO were compared for the presence of new velopharyngeal insufficiency (VPI), as measured by perceptual rating by a craniofacial speech-language pathologist. Of the 199 patients who underwent maxillary advancement, 126 were available for analysis. The DO group was younger, male, and had more severe maxillary hypoplasia. Following surgery, 17/41 (41.5%) of the DO group had new VPI, compared to just 23/85 (27.1%) of the CO group. After adjusting for cleft type and predicted maxillary advancement, however, there was not sufficient evidence to reject the null hypothesis of no difference in risk of post-operative VPI between the two surgical groups (prevalence ratio [PR] 1.40, 95% CI 0.68-2.90). Increased prevalence of VPI after DO versus CO was primarily observed among patients with a pre-operative velopharyngeal need ratio < 0.8 (PR = 2.01, 95% CI 0.79-5.10) and patients with normal velopharyngeal function pre-operatively (PR = 2.86, 95% CI 0.96-8.50). Our results suggest an increased rather than decreased risk of VPI following DO relative to CO. This association is primarily seen among those with a smaller velopharyngeal ratio or perceptually normal velopharyngeal function pre-operatively.
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Affiliation(s)
- Sara Kinter
- Department of Pediatrics, Division of Craniofacial Medicine, University of Washington, Seattle, WA, USA
- Craniofacial Center, Seattle Children’s Hospital, Seattle, WA, USA
| | - Srinivas Susarla
- Craniofacial Center, Seattle Children’s Hospital, Seattle, WA, USA
- Department of Oral & Maxillofacial Surgery, University of Washington, Seattle, WA, USA
- Department of Surgery, Division of Plastic Surgery, University of Washington, Seattle, WA, USA
| | - Joseph Christopher Delaney
- College of Pharmacy, University of Manitoba, Winnipeg, Canada
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Kathy Chapman
- Department of Communication Sciences & Disorders, University of Utah, Salt Lake City, UT, USA
| | - Hitesh Kapadia
- Craniofacial Center, Seattle Children’s Hospital, Seattle, WA, USA
- Department of Surgery, Division of Plastic Surgery, University of Washington, Seattle, WA, USA
- Department of Orthodontics, University of Washington, Seattle, WA, USA
| | - Noel Weiss
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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Nachmani A, Masalha M, Biadsee A, Nageris B, Ben-Dov T, Kassem F. Differences in craniofacial morphology between platybasic and nonplatybasic patients with velopharyngeal dysfunction and control subjects. Am J Orthod Dentofacial Orthop 2022; 162:e5-e16. [PMID: 35491327 DOI: 10.1016/j.ajodo.2021.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 12/01/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION This study aimed to identify the characteristics of cranial-base morphology in platybasic and nonplatybasic patients with palatal anomalies and velopharyngeal dysfunction (VPD) compared with control subjects to investigate structural factors related to craniofacial morphology that affect the nasopharyngeal space and may influence velopharyngeal function, and to develop precise treatments for specific patients with VPD. METHODS Three hundred eighty-six patients with VPD and various palatal anomalies were studied retrospectively. The control group included 126 healthy patients with normal speech. Lateral cephalometric images assessed craniofacial morphology. RESULTS Nonplatybasic patients and control subjects had larger SNA, S-Ba-Ptm, and N-Ba-PP angles (in the craniomaxillary complex), and platybasic patients had larger nasopharyngeal ANS-Ptm-Ve and Ba-S-Ptm angles and longer Ve-T and Ve-Ba distances than the nonplatybasic patients. All study patients had larger ANB, Gn-Go-Ar, and PP-MP angles (in the craniomandibular complex). Nonplatybasic patients had smaller Ba-SN angles than platybasic patients and controls because of more acute N-S-Ptm angle. Among the nonplatybasic patients, Ve-T length tended to be shorter (with no significant difference between groups) and located more inferiorly (because of the smallest ANS-Ptm-Ve angle) in relation to the maxilla. Thus, the nasopharynx was narrower horizontally but longer vertically than in patients with platybasia. CONCLUSIONS Cranial-base flexure influences the shape of the skull base and facial-skeletal structure and may alter the pharyngeal space between them. This finding should help improve preoperative planning regarding the effect of the pharyngeal flap height relative to the nasopharynx and oropharynx ratio that affects surgical outcomes, such as resonance and residual VPD. In patients with Class III malocclusion and maxillary constriction, careful planning of presurgical orthodontic treatment is needed in maxillary advancement procedures. Orthodontic and surgical collaboration can help prevent postoperative VPD, especially in platybasic patients.
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Affiliation(s)
- Ariela Nachmani
- Faculty of Communication Disorders, Hadassah Academic College, Jerusalem, Israel; Department of Communication Disorders, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Muhamed Masalha
- Department of Otolaryngology, Head and Neck Surgery, Emek Medical Center, Afula, Israel; The Ruth and Bruce Rappaport School of Medicine, The Technion Institute of Technology, Haifa, Israel
| | - Ameen Biadsee
- Department of Otolaryngology-Head and Neck Surgery, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ben Nageris
- Department of Otolaryngology-Head and Neck Surgery, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tom Ben-Dov
- Department of Otolaryngology-Head and Neck Surgery, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Firas Kassem
- Department of Otolaryngology-Head and Neck Surgery, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Maryn Y, Zarowski A, Loomans N. Exploration of the Influences of Temporary Velum Paralysis on Auditory-Perceptual, Acoustic, and Tomographical Markers. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2021; 64:4149-4177. [PMID: 34699253 DOI: 10.1044/2021_jslhr-20-00587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Purpose To better understand hypernasality (HN), we explored the relations between velopharyngeal orifice, auditory perception of HN, and acoustic-spectral measures in an in vivo within-subject design: (a) with a normally functioning velum as the control condition and (b) with a temporarily paralyzed velum as the experimental condition. Method The velum of eight volunteers was injected with ropivacaine hydrochloride (Naropin) in the area of the levator veli palatini and tensor veli palatini muscles to induce temporary velopharyngeal inadequacy (VPI) and HN. Sustained [a] and [i] and oronasal text readings were recorded, and 3D cone-beam computed tomography images of the vocal tract were built before and during velar anesthesia. Differences between conditions and correlations in normal-to-numb differences between velopharyngeal cross-sectional area (VParea), mean ratings of HN severity, and nine acoustic-spectral measures were determined. Results Three subjects already had some incomplete velopharyngeal closure in the control condition. Temporary motor nerve blockage of the velum (increased VParea) was accomplished in seven subjects, leading to increased HN and changes in three acoustic-spectral measures. Furthermore, significant correlations only emerged between VParea, HN, and ModelKataoka. Conclusions In most of the participants, it was possible to temporarily increase the velopharyngeal orifice to investigate HN while controlling other speech variables and cephalic morphology. Although this study was exploratory and its are findings preliminary, it provided additional evidence for the possible clinical value of ModelKataoka, A 3-P 0, and B F1 for the objective measurement of VPI or HN.
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Affiliation(s)
- Youri Maryn
- Department of Otorhinolaryngology & Head and Neck Surgery, European Institute for ORL-HNS, GZA Sint-Augustinus, Wilrijk, Belgium
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Belgium
- Department of Speech-Language Therapy and Audiology, University College Ghent, Belgium
- School of Logopedics, Faculty of Psychology and Educational Sciences, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
- Phonanium, Lokeren, Belgium
| | - Andrzej Zarowski
- Department of Otorhinolaryngology & Head and Neck Surgery, European Institute for ORL-HNS, GZA Sint-Augustinus, Wilrijk, Belgium
| | - Natalie Loomans
- Department of Maxillo-Cranio-Facial Surgery, Craniofacial and Cleft Lip & Palate Team GZA Sint-Augustinus, Wilrijk, Belgium
- Face Ahead, Private Maxillo-Cranio-Facial Surgery Clinic, Antwerp, Belgium
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Denegri MA, Silva PP, Pegoraro-Krook MI, Ozawa TO, Yaedu RYF, Dutka JDCR. Cephalometric predictors of hypernasality and nasal air emission. J Appl Oral Sci 2021; 29:e20210320. [PMID: 34644782 PMCID: PMC8523092 DOI: 10.1590/1678-7757-2021-0320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 08/18/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND During times of increasingly recognized importance of interprofessional practices, professionals in Medicine, Dentistry, and Speech Pathology areas cooperate to optimize treatment of velopharyngeal dysfunction (VPD), after primary palatoplasty for correction of cleft palate. OBJECTIVE Our study aims to compare velar length, velar thickness, and depth of the nasopharynx of patients with unilateral cleft lip and palate (UCLP) with the presence, or absence, of hypernasality and nasal air emission; and to verify if the depth:length ratio, between nasopharynx and velum, would be predictive of consistent hypernasality and nasal air emission (speech signs of VPD). METHODOLOGY Cephalometric radiographs and outcome of speech assessment were obtained from 429 individuals, between 6 and 9 years of age, with repaired unilateral cleft lip and palate. Velar length, velar thickness, depth of the nasopharynx, depth:length ratio, scores of hypernasality, and scores of nasal air emission were studied and compared; grouping the radiographs according to presence or absence of hypernasality and nasal air emission. RESULTS For the group with speech signs of velopharyngeal dysfunction (those with consistent hypernasality and nasal air emission), the velums were shorter and thinner; the nasopharynx was deeper and the depth:length ratio was larger than the group without hypernasality and nasal air emission. Velar length was significantly shorter in individuals with consistent hypernasality and nasal air emission (p<0.001) and with history of palatal fistula (p=0.032). Depth of nasopharynx was significantly greater in individuals with consistent hypernasality and nasal air emission (p<0.001). Depthlength ratio was significantly larger in individuals with consistent hypernasality and nasal air emission (p<0.001). A depth:length ratio larger than 0.93 was always associated with speech signs of VPD. CONCLUSION Estimated with cephalometric radiographs, a depth:length ratio greater than 0.93, between the nasopharyngeal space and the velum, was 100% accurate in predicting hypernasality and nasal air emission after primary repair of unilateral cleft lip and palate.
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Affiliation(s)
- María Alicia Denegri
- Universidade de São Paulo, Hospital de Reabilitação de Anomalias Craniofaciais, Programa de Pós-Doutorado, Bauru, SP, Brasil.,Universidad Nacional de Cuyo. Facultad de Odontologia. Cátedra de Cirugía Bucomaxilofacial, Mendoza, Argentina
| | - Patrick Pedreira Silva
- Universidade de São Paulo, Hospital de Reabilitação de Anomalias Craniofaciais, Bauru-SP, Programa de Pós-Graduação em Ciências da Reabilitação, Bauru, SP, Brasil
| | - Maria Inês Pegoraro-Krook
- Universidade de São Paulo, Hospital de Reabilitação de Anomalias Craniofaciais, Bauru-SP, Programa de Pós-Graduação em Ciências da Reabilitação, Bauru, SP, Brasil.,Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Fonoaudiologia, Bauru, SP, Brasil.,Universidade de São Paulo, Faculdade de Odontologia de Bauru, Programa de Pós-Graduação em Fonoaudiologia, Bauru, SP, Brasil
| | - Terumi Okada Ozawa
- Universidade de São Paulo, Hospital de Reabilitação de Anomalias Craniofaciais, Bauru-SP, Programa de Pós-Graduação em Ciências da Reabilitação, Bauru, SP, Brasil.,Universidade de São Paulo, Hospital de Reabilitação de Anomalias Craniofaciais, Divisão de Odontologia, Setor de Ortodontia, Bauru, SP, Brasil
| | - Renato Yassutaka Faria Yaedu
- Universidade de São Paulo, Hospital de Reabilitação de Anomalias Craniofaciais, Bauru-SP, Programa de Pós-Graduação em Ciências da Reabilitação, Bauru, SP, Brasil.,Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Cirurgia, Estomatologia, Patologia e Radiologia, Bauru, SP, Brasil
| | - Jeniffer de Cássia Rillo Dutka
- Universidade de São Paulo, Hospital de Reabilitação de Anomalias Craniofaciais, Bauru-SP, Programa de Pós-Graduação em Ciências da Reabilitação, Bauru, SP, Brasil.,Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Fonoaudiologia, Bauru, SP, Brasil.,Universidade de São Paulo, Faculdade de Odontologia de Bauru, Programa de Pós-Graduação em Fonoaudiologia, Bauru, SP, Brasil
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Feitosa MCP, Garib D, de Cássia Moura Carvalho Lauris R, Herkrath APQ, Vettore MV. The impact of orthognathic surgery on quality of life in individuals with oral clefts. Eur J Orthod 2021; 44:170-177. [PMID: 34173641 DOI: 10.1093/ejo/cjab039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND/OBJECTIVES To evaluate the relationships between individual, environmental, clinical factors and oral health-related quality of life (OHRQoL) in patients with cleft lip and palate (CLP) following orthognathic surgery. MATERIALS AND METHODS A follow-up study was conducted involving 69 adults with unilateral and bilateral CLP under orthodontic treatment. Interviews and oral examinations were conducted prior to orthognathic surgery (T0) to evaluate age, gender, psychological well-being, dental caries, malocclusion, social support, social networks, family income and education and OHRQoL. All participants were reviewed after 6 months (T1) to re-assess psychological well-being, malocclusion and OHRQoL. Structural equation modeling estimated the associations between the variables. RESULTS OHRQoL total scores reduced following orthognathic surgery, from 11.7 to 6.9 (P < 0.01). Occlusal characteristics and psychological well-being improved between T0 and T1. In the structural equation modeling, reduction of malocclusion (β = 0.02) between T0 and T1 directly predicted poor OHRQoL at T1. Improvement of psychological well-being between T0 and T1 was associated with better OHRQoL at T1 (β = -0.07). Dental caries and malocclusion at T0 were indirectly linked to poor OHRQoL at T1 (β = 0.02). LIMITATIONS The short follow-up period of 6 months after orthognathic surgery. CONCLUSIONS/IMPLICATIONS This represents the first prospective study examining the interrelationships of predictors of OHRQoL in patients with CLP after orthognathic surgery. OHRQoL and psychological well-being improved after orthognathic surgery. Clinical and psychological characteristics were important determinants of OHRQoL. These findings suggest the importance of the biopsychosocial model of health and the patient-centered approach in oral health care in individuals with CLP.
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Affiliation(s)
- Mariana Chaves Petri Feitosa
- Dental Division, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, SP, Brazil
| | - Daniela Garib
- Dental Division, Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo, Bauru, SP, Brazil.,Department of Orthodontics, Bauru Dental School, University of São Paulo, Bauru, SP, Brazil
| | | | | | - Mario Vianna Vettore
- Department of Health and Nursing Sciences, University of Agder, Kristiansand, Norway
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Yao CF, Bhandari K, Lee MC, Chen PKT, Lu TC. Videofluoroscopic Findings as Predictors of Velopharyngeal Insufficiency After Orthognathic Surgery in Patients With Cleft Lip and Palate. Ann Plast Surg 2021; 86:S46-S51. [PMID: 33346546 DOI: 10.1097/sap.0000000000002654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Midface retrusion is a common problem in patients with cleft lip and palate owing to the lack of adequate growth of the maxilla. Midface advancement surgery is a definite treatment for midface retrusion; however, the subsequent oropharyngeal airway changes might result in velopharyngeal insufficiency (VPI) in affected patients. Determining the predictors of VPI beforehand and modifying the surgical procedure would be beneficial. MATERIALS AND METHODS A retrospective review of 42 patients with cleft lip and palate who underwent orthognathic surgery from 2013 to 2014 was performed. A total of 25 patients met the inclusion criteria and had undergone complete pre- and postsurgery videofluoroscopy, nasopharyngoscopy (NPS), and speech assessment. We compared 2 groups of patients, those who showed NPS finding changes of more than 0.1 (8 patients) and those without changes (17 patients), by measuring the distances of the contact point to the tip of the velum, gap size at maximum closure (MC) and rest, contact area length, lateral wall closure rate, closure velocity, and 2 angles (from the velum to the hard palate and genu) at MC and rest. The amount of maxillary advancement was also recorded. RESULTS Among the 8 patients with NPS finding changes, 3 underwent Furlow palatoplasty for VPI. No significant difference was found in the amount of maxillary advancement between the groups (5.8 vs 5.7 mm). Significant differences were found in the preoperative gap size at MC and angle at the genu at MC (P = 0.035 and .012). These could be considered as the predictors before surgery. After surgery, a significant difference was found in the contact area, lateral wall closure rate, and gap size at MC (P = 0.005, 0.018, and 0.01). CONCLUSION Videofluoroscopy is a relatively applicable method of determining dynamic changes in the velum function. By performing videofluoroscopy before midface advancement surgery in patients with cleft lip and palate, we may predict the risk of VPI and consider alternative surgical strategies.
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Affiliation(s)
- Chuan-Fong Yao
- From the Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital
| | - Kishor Bhandari
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan
| | - Min-Chao Lee
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung
| | - Philip Kuo-Ting Chen
- Department of Plastic and Reconstructive Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ting-Chen Lu
- From the Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital
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Identifying Predictors of Acquired Velopharyngeal Insufficiency in Cleft Lip and Palate Following Maxillary Osteotomy Using Multiple Regression Analyses. J Craniofac Surg 2020; 31:2260-2266. [PMID: 33136867 DOI: 10.1097/scs.0000000000006775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Maxillary osteotomy is typically undertaken to correct abnormal facial growth in cleft lip and palate. The surgery can cause velopharyngeal insufficiency resulting in hypernasality. This study aims to identify valid predictors of acquired velopharyngeal insufficiency following maxillary osteotomy by using a range of perceptual and instrumental speech investigations and multiple regression. METHODS A prospective study was undertaken consisting of a consecutive series of patients with cleft lip and palate (N = 20) undergoing maxillary osteotomy by a single surgeon. Participants were seen at: 0 to 3 months pre-surgery (T1), 3-months (T2), and 12-months (T3) post-surgery. Hypernasality was rated using the cleft audit protocol for speech-augmented (CAPS-A) and visual analog scales, and nasalance was measured on the Nasometer II 6400. For lateral videofluorosopic and nasendoscopic images, visual perceptual ratings and quantitative ratiometric measurements were undertaken. Multiple regression analyses were undertaken to identify predictors. RESULTS T3 models with hypernasality as the dependent variable were found to be a good fit and significant (eg, CAPS-A: R2 = 0.920, F(11,7) = 7.303, P = 0.007). Closure ratio (a quantitative ratiometric measurement) and proportion of palate contacting the posterior pharyngeal wall (a visual perceptual rating) were identified as significant predictors for the CAPS-A model (P = 0.030, P = 0.002).
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Medeiros-Santana MNLD, Araújo BMAM, Fukushiro AP, Trindade IEK, Yamashita RP. Surgical maxillary advancement and speech resonance: comparison among cleft types. Codas 2020; 32:e20190152. [PMID: 32401996 DOI: 10.1590/2317-1782/20202019152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/09/2019] [Indexed: 11/22/2022] Open
Abstract
Purpose This study investigated the influence of the cleft type on the appearance of hypernasality after surgical maxillary advancement (MA). Methods Nasality was determined by measurement of nasalance (acoustic correlate of nasality) by nasometry. The study involved analysis of the nasalance scores of 17 individuals with isolated cleft palate (CP), 118 with unilateral cleft lip and palate (UCLP) and 69 with bilateral cleft lip and palate (BCLP), of both sexes, aged 18 to 28 years, after MA. Only individuals with normal nasalance scores indicating balanced resonance before MA were included in this study. Nasometry was performed 3 days before and 15 months after MA, on average. The proportion of patients who presented nasalance scores indicating hypernasality after surgery was calculated by the ANOVA test, and comparison among the different cleft types was evaluated by the chi-square test (p < 0.05). Results No significant difference was found in the proportions of individuals with hypernasality among the cleft types. Conclusion Nasometry showed that the appearance of hypernasality after MA in individuals with cleft palate with or without cleft lip occurred in similar proportions, regardless of the cleft type.
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Affiliation(s)
| | | | - Ana Paula Fukushiro
- Laboratório de Fisiologia, Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Bauru, SP, Brasil
| | - Inge Elly Kiemle Trindade
- Laboratório de Fisiologia, Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Bauru, SP, Brasil
| | - Renata Paciello Yamashita
- Laboratório de Fisiologia, Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo, Bauru, SP, Brasil
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